Method for correction of posture dependence on heart sounds

ABSTRACT

A system to monitor heart sounds. The system comprises an implantable heart sound sensor configured to produce an electrical signal representative of at least one heart sound, an implantable posture sensor operable to produce an electrical signal representative of a patient&#39;s posture, and a controller circuit. The controller circuit is configured to determine a patient posture, measure at least one heart sound in correspondence with at least one corresponding patient posture, adjust the heart sound measurement by using the corresponding determined patient posture to reduce or remove variation in the heart sound measurement due to patient posture, detect a change in the adjusted heart sound measurement, and provide an indication of congestive heart failure to a user or an automated process in response to the detected change.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a Continuation of U.S. application Ser. No. 11/037,275, filed on Jan. 18, 2005, now U.S. Pat. No. 7,662,104, which is incorporated herein by reference in its entirety.

This application is related to the following co-pending, commonly assigned U.S. patent applications: Ser. No. 10/900,570, entitled “DETERMINING A PATIENT'S POSTURE FROM MECHANICAL VIBRATIONS OF THE HEART,” filed on Jul. 28, 2004, now issued as U.S. Pat. No. 7,559,901, Ser. No. 10/703,175, entitled “A DUAL USE SENSOR FOR RATE RESPONSIVE PACING AND HEART SOUND MONITORING,” filed on Nov. 6, 2003, now issued as U.S. Pat. No. 7,248,923, and Ser. No. 10/334,694 entitled “METHOD AND APPARATUS FOR MONITORING OF DIASTOLIC HEMODYNAMICS,” filed on Dec. 30, 2002, which are hereby incorporated by reference.

TECHNICAL FIELD

The field generally relates to implantable medical devices and, in particular, but not by way of limitation, to systems and methods for monitoring the mechanical functions of the heart.

BACKGROUND

Implantable medical devices (IMDs) are devices designed to be implanted into a patient. Some examples of these devices include cardiac rhythm management (CRM) devices such as implantable pacemakers, implantable cardioverter defibrillators (ICDs), and devices that include a combination of pacing and defibrillation. The devices are typically used to treat patients using electrical therapy and to aid a physician or caregiver in patient diagnosis through internal monitoring of a patient's condition. The devices may include electrical leads in communication with sense amplifiers to monitor electrical heart activity within a patient, and often include sensors to monitor other internal patient parameters. Other examples of implantable medical devices include implantable insulin pumps or devices implanted to administer drugs to a patient.

Heart sounds are associated with mechanical activity of a patient's heart. The first heart sound (S1) is the sound made by the heart during the near simultaneous closure of the mitral and tricuspid valves. The second heart sound (S2) marks the beginning of diastole. The third heart sound (S3) and fourth heart sound (S4) are related to filling pressures of the left ventricle during diastole.

SUMMARY

This document discusses, among other things, systems and methods for monitoring heart sounds. One system embodiment includes an implantable heart sound sensor operable to produce an electrical signal representative of at least one heart sound, a heart sound sensor interface circuit coupled to the heart sound sensor to produce a heart sound signal, an implantable posture sensor operable to produce an electrical signal representative of a patient's posture, and a controller circuit. The controller circuit is coupled to the heart sound sensor interface circuit and the posture circuit and is operable to measure the at least one heart sound in correspondence with at least one sensed patient posture.

One method embodiment includes sensing at least one heart sound using an implantable medical device, determining posture information of a patient using the implantable medical device, and measuring the heart sound in correspondence with the posture information.

This summary is intended to provide an overview of the subject matter of the present patent application. It is not intended to provide an exclusive or exhaustive explanation of the invention. The detailed description is included to provide further information about the subject matter of the present patent application.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 illustrates an embodiment of a system that uses an implantable medical device.

FIG. 2 is a graph of heart sound data.

FIG. 3 shows portions of an embodiment of a system for monitoring heart sounds.

FIG. 4 shows portions of another embodiment of a system for monitoring heart sounds.

FIG. 5 is a block diagram of an embodiment of a method for monitoring heart sounds.

DETAILED DESCRIPTION

In the following detailed description, reference is made to the accompanying drawings which form a part hereof, and specific embodiments in which the invention may be practiced are shown by way of illustration. It is to be understood that other embodiments may be used and structural or logical changes may be made without departing from the scope of the present invention.

Monitoring of heart sounds aids caregivers in determining the condition of a patient's heart. For example, chronic changes in S3 amplitude is correlated to left ventricular chamber stiffness and degree of restrictive filling. For a patient with congestive heart failure (CHF), S3 heart sounds become louder as the disease progresses. IMDs can include sensors to assist caregivers in monitoring internal patient parameters such as heart sounds. However, heart sound amplitude varies with patient posture. The present inventors have recognized a need for improved measurement of heart sounds.

The present application discusses, among other things, systems and methods for monitoring heart sounds. FIG. 1 illustrates an embodiment of a system 100 that uses an IMD 110. The system 100 shown is one embodiment of portions of a system 100 used to treat a cardiac arrhythmia or otherwise improve heart function. A pulse generator (PG) or other IMD 110 is coupled by a cardiac lead 108, or additional leads, to a heart 105 of a patient 102. Examples of IMD 110 include, without limitation, a pacer, a defibrillator, a cardiac resynchronization therapy (CRT) device, or a combination of such devices. System 100 also includes an IMD programmer or other external system 170 that provides wireless communication signals 160 to communicate with the IMD 110, such as by using radio frequency (RF) or other telemetry signals.

Cardiac lead 108 includes a proximal end that is coupled to IMD 110 and a distal end, coupled by an electrode or electrodes to one or more portions of a heart 105. The electrodes typically deliver cardioversion defibrillation, pacing, resynchronization therapy, or combinations thereof to at least one chamber of the heart 105. IMD 110 includes components that are enclosed in a hermetically-sealed canister or “can.” Additional electrodes may be located on the can, or on an insulating header, or on other portions of IMD 110, for providing unipolar pacing and/or defibrillation energy in conjunction with the electrodes disposed on or around heart 105. The lead 108 or leads and electrodes are also used for sensing electrical activity of a heart 105.

Implantable heart sound sensors are generally implantable acoustic sensors that convert the detected sounds of the heart into electrical signals. An example of an acoustic sensor is an accelerometer mounted within the can. The amplitude of the several heart sounds as measured by acoustic sensors typically varies significantly with the posture of the patient when the measurement is taken. This typically confounds use of heart sound information.

FIG. 2 is a graph 200 of heart sound data taken from nineteen individuals. The data is a measure of S3 heart sounds using an accelerometer heart sound sensor while the individuals were in four postures: seated (s), recumbent (r), left recumbent (1 r), and right recumbent (rr). The individuals were upright when seated, and were at an angle from 0° to 45° when recumbent. Left recumbent refers to the individual being recumbent laterally on their left side and right recumbent refers to an individual being recumbent laterally on their right side. The heart sound sensor was mounted externally on the individuals on the left side of the chest near their pectoral region. The force on the sensor was measured in milli-Gs (“G” refers to G-force, i.e. the average acceleration produced by gravity at the earth's surface). The measurements shown are peak-to-peak amplitudes.

The graph 200 shows that a change in posture for some patients can result in a change as high as 100%-200% in measured S3 amplitudes. These changes in amplitudes due to posture are caused both by changes in coupling of the heart sound sensor to the surrounding tissue and hemodynamic changes in the circulatory system. Hemodynamic changes in the circulatory system cause changes in stiffness of tissue. Because this tissue is the medium for heart sounds to propagate to the sensor, changes in the stiffness of the tissue changes the ability of the heart sound vibrations to travel through the tissue and reach the sensor. If patient posture is not accounted for in heart sound measurements, the posture dependence may mask changes in heart sounds that are actually due to disease progression, such as the increase in S3 amplitude due to CHF.

FIG. 3 shows portions of an embodiment of a system 300 for monitoring heart sounds. The system 300 includes a device that in turn includes an implantable heart sound sensor 310, a heart sound sensor interface circuit 320 coupled to the heart sound sensor 310, an implantable posture sensor 330, and a controller circuit 340 coupled to the heart sound sensor interface circuit 320 and the implantable posture sensor 330. The implantable heart sound sensor 310 is operable to produce an electrical signal representative of at least one heart sound that is associated with mechanical activity of a patient's heart. In some embodiments, the implantable heart sound sensor 310 includes an accelerometer. In some embodiments, the heart sound sensor 310 includes a strain gauge. In some embodiments, the heart sound sensor 310 includes a microphone. The heart sound sensor interface circuit 320 provides signals representative of one or more heart sounds to the controller circuit 340. Measurements of the signals are made in relation to a physiological event, such as synchronizing the measurement to a sensed heart depolarization. Descriptions of making heart sound measurements in relation to heart depolarization are found in U.S. patent application Ser. No. 10/334,694 entitled, “Method and Apparatus for Monitoring of Diastolic Hemodynamics,” which is hereby incorporated by reference.

The implantable posture sensor 330 is operable to produce an electrical signal representative of a patient's posture. In some embodiments, the posture sensor 330 includes at least one DC responsive accelerometer. In some embodiments, the posture sensor 330 includes a multi-axis DC responsive accelerometer sensor. In some embodiments, the posture sensor 330 includes a mechanical tilt switch. The controller circuit 340 is operable to measure at least one heart sound in correspondence with at least one sensed patient posture using the heart sound sensor and the posture sensor. The heart sound includes at least one of the S1, S2, S3, and S4 heart sounds. In some embodiments, a heart sound measurement includes a measure of the amplitude of the heart sound signals. In some embodiments, a heart sound measurement includes sampling of the heart sound during a window of time when the heart sound occurs.

The controller circuit 340 is operable to detect a posture of the patient from a signal or signals provided by the posture sensor 330. The controller circuit 340 is operable by executing an algorithm or algorithms implemented by hardware, software, firmware or any combination of hardware, software or firmware. In some embodiments, the controller 340 executes a heart sound measurement in relation to a time of day, such as when a patient is likely to be asleep for example. In some embodiments, the measurement is made occasionally or periodically throughout the day, such as hourly. In some embodiments, the measurement is made in relation to a change in posture.

According to some embodiments, the controller is operable to measure the at least one heart sound while the patient is in an upright posture. In some embodiments, the controller 340 only executes a heart sound measurement when an upright posture is detected in the patient. An upright posture refers to a standing or a seated posture for example. In some embodiments, the device further includes a memory circuit coupled to the controller 340, and the controller 340 only stores a heart sound measurement when an upright posture is detected.

In some embodiments, the controller is operable to measure a heart sound in a plurality of postures. The heart sound measurement is made in correspondence with patient posture. In some embodiments, the heart sound measurement is stored in correspondence with a patient posture. For example, the controller 340 stores a set of heart sound measurements made when the patient is in a supine position and stores a set of heart sound measurements made when the patient is in an upright position. In another example, the controller 340 stores heart sound measurements made when the patient is in a recumbent position and when a patient is in an upright position. In some embodiments, heart sound measurements are categorized, or “binned,” according to posture. Trends in the heart sounds are then determined by comparing measurements in the same “bin.” Thus, problems associated with interpreting a set of heart sound measurements from varying postures are avoided.

In some embodiments, a scaling factor is applied to a heart sound measurement. The scaling factor is determined as a function of posture. The scaling factor is applied to the heart sound measurements to remove the variation with posture. For example, if S2 heart sounds for a patient in an upright position are found to have one-half the amplitude of S2 heart sounds for the patient in a recumbent position, the upright heart sound measurements are multiplied by a scaling factor of two while the recumbent heart sound measurements are multiplied by a scaling factor of one or left unaltered. If the variation with posture is removed through scaling, trends in the heart sounds can then be determined by comparing measurements directly without regard to a particular posture or bin.

According to some embodiments, the heart sounds may be stored according to seated, recumbent, and supine postures, and further, according to left and right lateral orientations. In some embodiments, the number of postures detected by the system 300 may be limited by the performance of the implantable posture sensor 330. For example, the posture sensor 330 may only be able to detect the difference between an upright posture and a supine posture. In another example, the posture sensor 330 may only be able to detect one of several postures with an accuracy of 15°. In such a case, the controller circuit 340 could be programmed to define supine as 0° to 30° as measured from the horizontal, recumbent as 30° to 60° and upright as 60° to 90°. In another example, the posture sensor 330 may be unable to detect a lateral orientation of a patient. Use of posture sensors may involve calibrating the sensors to the patient. A caregiver may put a patient in the different postures to calibrate the response of the sensor to detect that posture.

Heart sound measurements are susceptible to noise from movement and other non-cardiac vibrations such as talking. According to some embodiments, the heart sound sensor 310 is used to detect mechanical interference from non-cardiac vibrations. The controller circuit 340 uses signals provided by the heart sound sensor 310 to determine that the interference level is below a threshold interference level before a heart sound measurement is executed. In some embodiments, the controller circuit 340 determines the level of interference by monitoring the heart sound signal outside of a window of time when the heart sound occurs. In some embodiments, the controller circuit 340 determines the level of interference by a method that includes averaging the heart sound signal over a period of time. In some embodiments, the controller circuit 340 determines the level of interference by a method that includes digital signal processing (DSP) of the heart sound signal, such as to extract spectral components associated with heart sounds from interfering sounds.

Heart sound measurements are less susceptible to noise and interference from artifacts of patient movement if they are taken during a period of patient inactivity. To determine patient inactivity, some embodiments of the device further include an implantable activity sensor, such as an accelerometer (which can be the same accelerometer as the heart sound sensor or a different accelerometer). The activity sensor detects a level of patient physical activity. The controller circuit 340 is operable to measure at least one heart sound in correspondence with at least one sensed patient posture when a patient activity level is below a specified activity threshold value. For example, if the controller circuit 340 is operable to take a heart sound measurement every fifteen minutes, the controller circuit 340 may first determine if the patient is in an upright position and is inactive before executing the measurement. In some embodiments, the activity sensor is different from the heart sound sensor 310. In other embodiments, the activity sensor is the same as the heart sound sensor 310 and patient activity is determined by signal processing to isolate the activity signals.

Patient inactivity can also be determined or inferred by the time of day. Thus, in some embodiments, the device further includes a clock circuit and the controller circuit 340 is operable to measure heart sounds when it is likely that a patient is sleeping.

Patient inactivity can also be determined from other physiologic parameters. For example, a low patient heart rate may be an indication of patient inactivity. Thus, in some embodiments, the device further includes at least one implantable cardiac signal sensing circuit. The cardiac signal sensing circuit is operable to detect at least one intrinsic cardiac signal, and the controller circuit 340 is operable to measure the at least one heart sound in correspondence with at least one sensed patient posture when a patient heart rate is below a specified heart rate threshold value.

In some embodiments, patient inactivity is determined from the heart sound themselves. The controller circuit 340 detects heart sounds but waits to measure and store a heart sound until the heart sounds indicates the patient is inactive. In some embodiments, the controller makes and stores a heart sound measurement when a period of time between heart sounds are longer than a threshold period, i.e. when a heart, as determined by heart sounds, is below a threshold rate.

Patient inactivity can also be determined from a patient breathing rate. Thus, in some embodiments, the implantable medical device further includes a trans-thoracic impedance measurement circuit to provide a trans-thoracic impedance signal of a subject. The controller circuit 340 is operable to determine breathing volume from the trans-thoracic impedance signal, and to measure the at least one heart sound in correspondence with at least one sensed patient posture when a patient breathing rate is below a specified breathing rate threshold value. Illustrative examples of methods of monitoring lung tidal volume by measuring trans-thoracic impedance are described in Hartley et al. U.S. Pat. No. 6,076,015 entitled “RATE ADAPTIVE CARDIAC RHYTHM MANAGEMENT DEVICE USING TRANSTHORACIC IMPEDANCE,” which is incorporated herein by reference.

According to some embodiments, one or more heart sound measurements are combined with one or more measurements of one or more other physiologic sensors, such as a trans-thoracic impedance sensor or a cardiac signal sensor, to provide a measurement of patient health. In some embodiments, one or more heart sound measurements are combined with one or more measurements of other physiologic sensors in correspondence with at least one sensed patient posture. As an example of such embodiments, trending of heart sound measurements can be combined with trans-thoracic impedance measurements in correspondence with at least one sensed patient posture to track the condition of a congestive heart failure patient. As another example, the trans-thoracic impedance measurement circuit provides a measurement of near-DC trans-thoracic impedance, and the controller is operable to provide the near-DC trans-thoracic impedance measurement in correspondence with at least one sensed patient posture and the heart sound measurement. Illustrative examples of methods of monitoring near-DC trans-thoracic impedance are described in Stahmann et al. U.S. patent application Ser. No. 10/921,503 entitled “THORACIC IMPEDANCE DETECTION WITH BLOOD RESISTIVITY COMPENSATION,” which is incorporated herein by reference. Other examples of measurements of other physiologic sensors include using a measure of hematocrit in blood of the subject, or using a measure of resistivity of blood within a heart.

FIG. 4 shows portions of an embodiment of a system 400 for monitoring heart sounds. The system 400 includes an implantable device 405 and an external device 410 operable to communicate with the implantable device 405. The implantable device 405 includes a heart sound sensor 415, a heart sound sensor interface circuit 420, and posture sensor 425 coupled to control circuit 430. The controller circuit 430 is operable to measure the at least one heart sound in correspondence with at least one sensed patient posture. The implantable device 405 also includes a memory circuit 435, a sensing circuit 440, and a therapy circuit 445. The memory circuit 435 stores heart sound measurements. The sensing circuit 440 is coupled to a cardiac lead or leads to sense cardiac signals from a subject's heart. The therapy circuit 445 is attached to a cardiac lead or leads to provide cardioversion defibrillation, pacing, resynchronization therapy, or combinations thereof to at least one chamber of the heart.

In an embodiment, the controller circuit 430 measures the S3 heart sounds using the heart sound sensor 415 for the purpose of monitoring ventricular diastolic hemodynamic performance over time. By monitoring the posture sensor 425, the controller circuit 430 measures the S3 heart sounds while the patient is in an upright posture to reduce variations in the measurements due to patient posture. Based on the S3 heart sound measurements, the controller circuit 430 controls delivery of at least one therapy, such as pacing resynchronization therapy for example, using the therapy circuit 445.

The implantable device 405 further includes a communication circuit 450. The external device 410 communicates wirelessly with the implantable device 405 by using radio frequency (RF) or other telemetry signals. The implantable device 405 communicates heart sound information to the external device 410. In some embodiments, the external device 410 is part of, or is in communication with, a computer network such as a hospital computer network or the internet. According to some embodiments, the external device 410 is operable to communicate an alarm based on the heart sound information and the posture information. In some embodiments, the alarm includes an audio alarm or a visual alarm indication. In some embodiments, an alarm is communicated via the network to a caregiver.

According to some embodiments, the external device 410 includes a display operable to display heart sound information in relation to sensed patient posture. In some embodiments, the heart sound information includes a trend of heart sound information in relation to patient posture. The trend information is useful to establish a trend indicative of a disease status of a patient or subject. This status can be an indication of worsening status or improving status.

In some embodiments, the trend information consists entirely of heart sound information corresponding to a single posture. In some embodiments, the trend information consists of heart sound information corresponding to a range of postures, e.g., the range from a recumbent posture to an upright posture. In some embodiments, a trend is maintained for each posture. In some embodiments, heart sound variation with posture is removed by using one or more scaling factors and the heart sound information is combined into a single trend. In some embodiments, the trend or trends of heart sound information is maintained in the implantable device 405, the external device 410, or both. In some embodiments, analyses on the heart sound information for multiple separate trends, such as a separate trend for each of supine, seated, and recumbent postures are combined to form a single decision as to whether to generate an alarm. In some embodiments, the analyses are combined with one or more measurements of one or more other physiologic sensors. These analyses can be done in the implantable device 405, the external device 410, or both.

FIG. 5 is a block diagram of an embodiment of a method 500 for monitoring heart sounds. At 510, at least one heart sound is sensed using an implantable medical device. In some embodiments, sensing at least one heart sound includes sensing at least one of the S1, S2, S3, and S4 heart sounds, and the measurement of at least one heart sound is performed when a heart rate is below a specified heart rate threshold value. In some embodiments, the measurement of at least one heart sound is performed when a patient activity level is below a specified activity threshold value. In some embodiments, the measurement of at least one heart sound is performed when a mechanical interference level is below a threshold value.

At 520, posture information of a patient is determined using the implantable medical device, and at 530, the heart sound is measured in correspondence with the posture information. In some embodiments, measuring at least one heart sound in correspondence with the posture information includes measuring heart sounds in correspondence with respective postures and relating a heart sound measurement to a particular posture. In some embodiments, measuring the at least one heart sound in correspondence with respective postures includes applying at least one scaling factor as a function of posture to at least one heart sound measurement. In some embodiments, measuring at least one heart sound in correspondence with the patient's posture includes measuring the heart sound contingent on the patient being in a specified posture, such as for example an upright posture.

According to some embodiments, measuring at least one heart sound in correspondence with the patient's posture includes measuring at least one trend of heart sounds in relation to posture. In some embodiments the heart sound trend information is combined with trending of measurements from other physiologic sensors. In some embodiments, trending information of measurements of the at least one heart sound is stored in correspondence with the patient's posture. In some embodiments, the method 500 further includes communicating the trending information to an external device for display.

The accompanying drawings that form a part hereof, show by way of illustration, and not of limitation, specific embodiments in which the subject matter may be practiced. The embodiments illustrated are described in sufficient detail to enable those skilled in the art to practice the teachings disclosed herein. Other embodiments may be utilized and derived therefrom, such that structural and logical substitutions and changes may be made without departing from the scope of this disclosure. This Detailed Description, therefore, is not to be taken in a limiting sense, and the scope of various embodiments is defined only by the appended claims, along with the full range of equivalents to which such claims are entitled.

Such embodiments of the inventive subject matter may be referred to herein, individually and/or collectively, by the term “invention” merely for convenience and without intending to voluntarily limit the scope of this application to any single invention or inventive concept if more than one is in fact disclosed. Thus, although specific embodiments have been illustrated and described herein, it should be appreciated that any arrangement calculated to achieve the same purpose may be substituted for the specific embodiments shown. This disclosure is intended to cover any and all adaptations, or variations, or combinations of various embodiments. Combinations of the above embodiments, and other embodiments not specifically described herein, will be apparent to those of skill in the art upon reviewing the above description.

The Abstract of the Disclosure is provided to comply with 37 C.F.R. §1.72(b), requiring an abstract that will allow the reader to quickly ascertain the nature of the technical disclosure. It is submitted with the understanding that it will not be used to interpret or limit the scope or meaning of the claims. In addition, in the foregoing Detailed Description, it can be seen that various features are grouped together in a single embodiment for the purpose of streamlining the disclosure. This method of disclosure is not to be interpreted as reflecting an intention that the claimed embodiments require more features than are expressly recited in each claim. Rather, as the following claims reflect, inventive subject matter lies in less than all features of a single disclosed embodiment. Thus the following claims are hereby incorporated into the Detailed Description, with each claim standing on its own. 

1. An apparatus comprising: an implantable heart sound sensor configured to produce an electrical signal representative of at least one heart sound, the heart sound associated with mechanical activity of a patient's heart; an implantable posture sensor operable to produce an electrical signal representative of a patient's posture; and a controller circuit, communicatively coupled to the heart sound sensor interface circuit and the posture circuit, wherein the controller circuit is configured to: determine a patient posture using the posture sensor signal; measure the at least one heart sound in correspondence with at least one corresponding determined patient posture; adjust the heart sound measurement by using the corresponding determined patient posture to reduce or remove variation in the heart sound measurement due to patient posture; detect a change in the adjusted heart sound measurement; and provide an indication of congestive heart failure (CHF) to a user or an automated process in response to the detected change.
 2. The apparatus of claim 1, wherein the implantable heart sound sensor is configured to produce an electrical signal representative of an S3 heart sound, and wherein the controller circuit is configured to: measure the S3 heart sound in correspondence with the determined patient posture; detect a change in an adjusted S3 heart sound measurement; and generate an alarm indicative of progression of CHF in response to the detected change in the adjusted S3 heart sound measurement.
 3. The apparatus of claim 1, including: a therapy circuit communicatively coupled to the controller circuit and configured to provide electrical pacing therapy to the patient, and wherein the controller circuit is configured to initiate delivery of pacing resynchronization therapy according to the detected change in the adjusted heart sound measurement.
 4. The apparatus of claim 1, including: a trans-thoracic impedance sensor communicatively coupled to the controller circuit and configured to provide an electrical signal representative of trans-thoracic impedance of the patient, and wherein the controller circuit is configured to: measure trans-thoracic impedance of the patient in correspondence with the determined patient posture; and provide the indication of CHF according to the adjusted heart sound measurement and the measured trans-thoracic impedance.
 5. The apparatus of claim 4, wherein the trans-thoracic impedance sensor is configured to provide an electrical signal representative of near-DC trans-thoracic impedance, and wherein the controller circuit is configured to provide the indication of CHF according to the adjusted heart sound measurement and the measured near-DC trans-thoracic impedance.
 6. The apparatus of claim 1, including: an intra-cardiac impedance sensor communicatively coupled to the controller circuit and configured to provide an electrical signal representative of trans-thoracic impedance of the patient, and wherein the controller circuit is configured to: measure intra-cardiac impedance of the patient in correspondence with the determined patient posture, and provide the indication of CHF according to the adjusted heart sound measurement and the measured intra-cardiac impedance.
 7. The apparatus of claim 1, including: a hematocrit sensor communicatively coupled to the controller circuit and configured to provide an electrical signal representative of hematocrit of the patient, and wherein the controller circuit is configured to: measure hematocrit of the patient in correspondence with the determined patient posture; and provide an indication of patient health to a user or process according to the adjusted heart sound measurement and the measured hematocrit.
 8. The apparatus of claim 1, including: a trans-thoracic impedance sensor configured to provide an electrical signal representative of trans-thoracic impedance of the patient, and wherein the controller circuit is configured to: monitor trans-thoracic impedance of the patient; determine breathing rate using the monitored trans-thoracic impedance; and measure the heart sound in correspondence with the determined patient posture when the measured breathing rate indicates that the patient is inactive.
 9. The apparatus of claim 1, wherein the controller circuit is configured to: determine heart rate of the subject using sensed heart sounds; and measure a specified heart sound in correspondence with the determined patient posture and when the determined heart rate indicates that the patient is inactive.
 10. The apparatus of claim 1, including: an activity sensor communicatively coupled to the controller circuit and configured to provide an electrical signal representative of patient activity, and wherein the controller circuit is configured to: determine patient activity using the activity signal; and measure the heart sound in correspondence with the determined patient posture and when the controller circuit detects that the patient is inactive.
 11. A method comprising: determining posture of a patient using an implantable medical device; measuring a heart sound in correspondence with at least one corresponding determined patient posture; adjusting the heart sound measurement by using the corresponding determined patient posture for reducing or removing variation in the heart sound measurement due to patient posture; detecting a change in the adjusted heart sound measurement; and providing, in response to the detected change, an indication of CHF to a user or an automated process.
 12. The method of claim 11, wherein measuring a heart sound includes measuring an S3 heart sound in correspondence with the determined posture, wherein detecting a change includes detecting a change in an adjusted S3 heart sound measurement, and wherein providing an indication includes generating an alarm indicative of progression of CHF in response to the detected change in the adjusted S3 heart sound measurement.
 13. The method of claim 11, including initiating delivery of pacing resynchronization therapy according to the detected change in the adjusted heart sound measurement.
 14. The method of claim 11, including: measuring trans-thoracic impedance of the patient in correspondence with the determined patient posture, and wherein providing the indication of CHF includes providing the indication of CHF according to the adjusted heart sound measurement and the measured trans-thoracic impedance.
 15. The method of claim 14, wherein measuring trans-thoracic impedance includes measuring near-DC trans-thoracic impedance, and wherein providing the indication of CHF includes providing the indication of CHF according to the adjusted heart sound measurement and the measured near-DC trans-thoracic impedance.
 16. The method of claim 11, including: measuring intra-cardiac impedance of the patient in correspondence with the determined patient posture, and wherein providing the indication of CHF includes providing the indication of CHF according to the adjusted heart sound measurement and the measured intra-cardiac impedance.
 17. The method of claim 11, including: measuring hematocrit of the patient in correspondence with the determined patient posture; and providing an indication of patient health to a user or process according to the adjusted heart sound measurement and the measured hematocrit.
 18. The method of claim 11, including: measuring trans-thoracic impedance of the patient; determining breathing rate using the trans-thoracic impedance, and wherein measuring a heart sound includes measuring the heart sound in correspondence with the determined patient posture when the measured breathing rate indicates that the patient is inactive.
 19. The method of claim 11 including: determining heart rate of the subject using measured heart sounds, and wherein measuring the heart sound includes measuring the heart sound in correspondence with the determined patient posture and when the determined heart rate indicates that the patient is inactive.
 20. The method of claim 11, including: sensing patient activity using an activity sensor; and wherein measuring the heart sound includes measuring the heart sound in correspondence with the determined patient posture and when the activity sensor indicates the patient is inactive. 